title: The rise and fall of renal artery angioplasty and stenting in the United States, 1988-2009.
abstract: OBJECTIVE
  Optimal management of renal artery stenosis (RAS) remains unclear. Recent randomized controlled trials have shown no clear benefit with percutaneous transluminal angioplasty with or without stenting (PTRA/S) over medical management. We hypothesize that interventions for RAS are decreasing nationally.
  
  
  METHODS
  The Nationwide Inpatient Sample, 1988-2009, was used to identify patients with a diagnosis of renal artery atherosclerosis undergoing open surgical repair (bypass or endarterectomy) or PTRA/S. The rate of interventions, in-hospital death, and perioperative outcomes were analyzed over time. Additionally, we used individual state inpatient and ambulatory databases to better understand the influence of outpatient procedures on current volume and trends.
  
  
  RESULTS
  We identified 308,549 PTRA/S and 33,147 open surgical repairs. PTRA/S increased from 1.9/100K adults in 1988 to 13.7 in 2006 followed by a decrease to 6.7 in 2009. Open surgical repair steadily decreased from 1.3/100K adults in 1988 to 0.3 in 2009. In 2009, PTRA/S procedures (6.4/100K adults) greatly outnumbered procedures done by open repair alone (0.1/100K), combined open renal and aortic repair (0.2/100K), and combined PTRA/S and endovascular aneurysm repair (0.3/100K). From 2005 to 2009 33,953 patients underwent PTRA/S in the states of New Jersey Maryland, Florida, and California combined. The total number of PTRA/S performed in the outpatient setting remained stable from 2005 (3.8/100K) to 2009 (3.7/100K), whereas the total number of inpatient procedures mirrored the national trend, declining from 2006 (7.9/100K) to 2009 (4.2/100K). PTRA/S had lower in-hospital mortality (0.9% vs 4.1%; P < .001) compared with open repair. PTRA/S patients were more likely to be discharged home (86.2% vs 76.3%; P < .001) and had a shorter length of stay (4.4 vs 12.3 days; P < .001). Mortality was higher after combined open renal and open aortic surgery compared to open repair alone (6.5% vs 4.1%; P < .001). Mortality was similar for combined PTRA/S and endovascular aneurysm repair compared with PTRA/S alone (1.2% vs 0.9%; P = .04).
  
  
  CONCLUSIONS
  The performance of PTRA/S procedures for the management of RAS has decreased significantly after 2006. An increasing proportion of these procedures are performed in the outpatient setting. PTRA/S remains the dominant revascularization procedure for RAS with lower in-hospital mortality and morbidity than surgery.
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
authors.forename: Patric
authors.initials: P
authors.lastname: Liang
authors.forename: Rob
authors.initials: R
authors.lastname: Hurks
authors.forename: Rodney P
authors.initials: RP
authors.lastname: Bensley
authors.forename: Allen
authors.initials: A
authors.lastname: Hamdan
authors.forename: Mark
authors.initials: M
authors.lastname: Wyers
authors.forename: Elliot
authors.initials: E
authors.lastname: Chaikof
authors.forename: Marc L
authors.initials: ML
authors.lastname: Schermerhorn
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000639:trends; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality / Q000639:trends*; D016009:Chi-Square Distribution; D003131:Combined Modality Therapy; D004691:Endarterectomy / Q000639:trends; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D012078:Renal Artery Obstruction / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D012307:Risk Factors; D015607:Stents / Q000639:trends*; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology